Kimberly Grandal, Founder and Executive Director of Re-Creative Resources, Inc., is a strong advocate for the field of Therapeutic Recreation and Activities, with over fifteen years of experience working with the elderly in numerous management and consultant positions. She is an Activity Consultant Certified and a Certified Therapeutic Recreation Specialist. Kim is a member of the New Jersey Activity Professionals Association and the New Jersey/Eastern Pennsylvania Therapeutic Recreation Association.

In 1990, Kim graduated from William Paterson University with a BA in Sociology and later studied gerontology courses at Union County College and Therapeutic Recreation courses at Kean University. Throughout her career, Kim has been the Director of Therapeutic Recreation for several long-term care facilities, including one of NJ’s largest.

In 2006, Kim founded Re-Creative Resources Inc. She is a speaker for various state and local activity associations such as NJAPA, MOCAP, and NJACA, as well as the Society of Licensed Nursing Home Administrators of NJ. She also offers lectures for Re-Creative Resources Inc., local colleges, and community groups, and provides consultation and support to numerous facilities in the state.

Kim is the editor and writer for the “The Rec-Room", a monthly newsletter published by her company. In addition, she writes monthly articles for the Activity Directors Office newsletter, and has contributed articles to Creative Forecasting Magazine, and The Continuing Care Insite newsletter.

Kim is a recipient of the Kessler Institute of Rehabilitation 1997 Triumph of the Human Spirit Award. Her passion is to promote the field of Therapeutic Recreation and Activities and to unite Recreation Therapists and Activity Professionals. Kim currently serves on the NJAPA board as the Chairperson for the Legislation Committee.

AboutRe-CreativeResources Inc.

Re-Creative Resources, Inc. is committed to enhancing the lives of long-term care residents through the use of Therapeutic Recreation. We provide a variety of services such as Therapeutic Recreation seminars, in-services, resources, form development, program analysis and development, consultation, and support for activity professionals and recreational therapists. A selection of downloadable training materials and forms are available for your convenience as well as a free job posting site.

A Closer Look at the MDS 3.0:News and Overview for Activity and Recreation ProfessionalsBy Kimberly Grandal, CTRS, ACC/EDU

The MDS 3.0 implementation date is scheduled for October 1, 2010. CMS highly recommends that everyone should hold back from training until after the "Train-the-Trainer" sessions have been completed. The Train-The-Trainer sessions are scheduled for the spring of 2010.Although it’s still too early to start training the staff on how to complete the MDS 3.0, it’s important to keep abreast of any MDS 3.0 news. The RAI User Manual is available for download. It’s not too early to start reviewing these materials and familiarize yourself with the new terminology, form design and layout, and the process. This way you will be more prepared to ask questions when you are presented with specific training opportunities. I’ve begun reading various components of the RAI Version 3.0 Manual. The following is a summary of what I have gathered to date.Advantages of the MDS 3.0A 5-year CMS Nursing Home MDS 3.0 Validation Study suggests that the MDS 3.0 has many advantages such as:• Increased resident’s voice• Increased clinical relevance for assessment• Increased accuracy, both validity and reliability• Increased clarity and efficiency• 45% reduction in the average time for completion• Supports the movement of items toward future electronic formats

Downloads• The CMS website has the MDS 3.0 materials, forms, timetables, RAI User Manual, etc. available for download. Visit http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.aspTo download the MDS 3.0 RAI user manual scroll down the page and click on MDS 3.0 RAI Manual Jan 2010. The section for Customary Routine and Activities is called section F and is located in the Chapter 3 file folder. The section which refers to Recreation Therapy can be found in section 0, Special Treatments and Procedures.• You can also download sections F and O at www.recreativeresources.com/MDS3.0.htm• Other items to download on the CMS website include:o MDS 3.0 Item Subsets – A file that contains the various subsets of the MDS 3.0 assessment and tracking document such as admission, quarterly, annual, significant change, discharge, etc.o MDS 3.0 Item Matrix - This document identifies the items required for each type of assessment along with how the item is used (e.g. QMs, QIs, CATs, RUG-IV, or RUG-III).o MDS 3.0 Data Submission Specifications - Detailed data submission specifications for MDS 3.0.o MDS 3.0 CATs Specifications - This document provides Care Area Trigger (CAT) specifications for the MDS 3.0 items used in triggering the Care Area, the conditions for triggering, and Visual Basic code for triggering.EducationCMS provided a webcast, entitled, MDS 3.0: Part 1- An Introduction, on December 17, 2009. You can view this archived webcast for free at http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1074• This webcast was the first of a three part series focused on providing information about the MDS 3.0. The other webcasts in the series include:o 2nd Part: Coding the MDS 3.0 (late spring/early summer, 2010)o 3rd Part: CMS Programs impacted by the MDS 3.0 (summer, 2010

Resident Assessment Instrument OverviewThe Resident Assessment Instrument (RAI) version 3.0 is no different than the 2.0 version in that it is a structured, standardized approach for applying a problem identification process in nursing homes. Completion of the RAI includes: assessment, decision making, care planning, care plan implementation and evaluation.

Care Area AssessmentThe Care Area Assessment (CAA) process provides guidance on how to focus on problems, concerns or important issues that are identified in the comprehensive and MDS assessment. There are 20 CAA-s which include:

The MDS 3.0 identifies the actual or potential problem areas and the CAA process provides for further assessment. Care Area Triggers (CATs) replaced the MDS 2.0 Resident Assessment Protocol (RAPs). The triggers identify those who have or are at risk for developing various functional problems in any of the 20 CAAs and directs staff to evaluate further. The Care Area Resources is a list of resources that may be helpful in performing the assessment of a triggered care area. The Care Area Summary (Section V of the MDS 3.0), provides a location for documentation of the care areas that have triggered from the MDS and the decisions made during the CAA process regarding whether or not to proceed with care planning.

Just as with the MDS 2.0, further documentation for each triggered CAA is required. Documentation for each triggered CAA should describe:• The nature of the issue, concern or condition• Causes and contributing factors• Complications related to the specific care area• Risk factors• Need for referral or further evaluation by appropriate health care professionals• What research, resources or assessment tools were utilized

There are four types of triggers which can change how the CAA is reviewed:• Potential Problems• Broad Screening Triggers• Prevention of Problems• Rehabilitation Potential

In terms of activities, the purpose of the CAA is to identify strategies to assist the resident in increasing their involvement in meaningful activities that have been of interest to them in the past and to help them find new or adapted activities of interest to accommodate their current level of functioning. The CAA for activities is triggered when there are indications that the resident may have a decrease in involvement in social activities. The information from the assessment should be used to identify residents who may be uneasy in social relationships and activities. In addition, assessment information is to identify resident interests and identify possible causes or risk factors.

When residents trigger for activities, the CMS RAI Version 3.0 manual states that the focus of the care plan should be to address the underlying cause(s) and the development of the inclusion of activity programs customized to the resident’s interests and his or her abilities. Activities should focus on helping the resident fulfill his/her wishes, use cognitive skills and provide enjoyment as well opportunities for socialization with others.

Preferences for Customary Routine and Activities (Section F)A section with significant revisions is the “Preferences for Customary Routine and Activities”. The customary routine staff assessment is replaced by the MDS 3.0 Preference Assessment Tool. Residents are to be interviewed for their activity interests and routine preferences. The RAI Version 3.0 Manual suggests various ways for the interviewer to phrase the questions, probe for clarification of residents’ responses and to utilize adaptive techniques such as cue cards, an interpreter, opportunity to write out answers, etc. The residents are to rate the level of importance by using the following codes:1. Very important2. Somewhat important3. Not very important4. Not important at all5. Important, but can’t do or no choice (meaning the resident finds it important but feel he/she cannot do that at this time because of health or because of nursing home resources or scheduling.9. No response or non-responsive (resident, family or significant other refuses to answer or doesn’t know, if the resident does not respond to the question, or provides a nonsensical response. A nonsensical response is defined as, “any unrelated, incomprehensible or incoherent response that is not informative with respect to the item being rated”.When coding the activity preferences interview, no look back is provided. The resident is to respond to their current preferences while in the facility. Family members and significant others may be the primary respondent to the interview questions if the resident is unable to do so. In this case, the family member or significant other may have to consider past preferences if they are unsure of current preferences and the resident is unable to communicate.There is a series of questions that relates to the resident’s preferences for daily routine such as bathing, bedtime, clothing, etc. The questions relating to activities include:• How important is it to you to have books, newspapers, and magazines to read?• How important is it to you to listen to music you like?• How important is it to you to be around animals such as pets?• How important is it to you to keep up with the news?• How important is it to you to do things with groups of people?• How important is it to you to do your favorite activities?• How important is it to you to go outside to get fresh air when the weather is good?• How important is it to you to participate in religious services or practices?For residents who cannot answer the questions and a family member or significant other is not available to answer on behalf of the resident, a staff assessment of activities and daily preferences is conducted. Staff is instructed to observe the resident’s response during activity programs. A variety of routine and activity preferences are listed and staff is to check off each item as it applies in the last 7 days. The items listed are as follows:A. Choosing clothes to wearB. Caring for personal belongingsC. Receiving tub bathD. Receiving showerE. Receiving bed bathF. Receiving sponge bathG. Snacks between mealsH. Staying up past 8:00 p.m.I. Family of significant other involvement in care discussionsJ. Use of phone in privateK. Place to lock personal belongings L. Reading books, newspapers, or magazinesM. Listening to musicN. Being around animals such as petsO. Keeping up with the newsP. Doing things with groups of peopleQ. Participating in favorite activitiesR. Spending time away from the nursing homeS. Spending time outdoorsT. Participating in religious activities or practicesZ. None of the above

In a sample of individuals that completed the revised Preferences for Customary Routine and Activities (Section F), findings indicated that:• 81% rated the interview items as more useful for care planning• 80% found that the interview changed their impression of resident’s wants• 1% felt that some residents who responded didn’t really understand the items• More likely to report that post-acute residents appreciated being askedSpecial Treatments and Therapies (Section O)The RAI Version 3.0 Manual states that recreational therapy is not a skilled service according to the Social Security Act however, for purposes of the MDS, providers should record services for recreational therapy when the conditions for the provision of recreation therapy are as follows:• The physician orders recreation therapy that provides therapeutic stimulation beyond the general activity program;• The physicians order must include a statement of frequency, duration and scope of treatment;• The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a therapeutic recreation specialist;• The services are required and provided by a state licensed or nationally certified therapeutic recreation specialist or therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation specialist; and• The services must be reasonable and necessary for the resident’s condition.The assessor records the number of days and the minutes that recreation therapy was administered over the 7 day look back period. Sessions must be at least 15 minutes in length. The RAI Version 3.0 Manual states that therapy logs are not a MDS requirement but is standard of good clinical practice by all therapy professionals.It’s also important to note that when two clinicians work together, which may be common with a recreational therapist and an occupational therapist, the clinicians must split the time between the two disciplines.Music Therapy is included under Recreational Therapy as well.Recommendations• Visit the CMS website regularly using the link I provided above.• Download and print the items that are available on the CMS website and put it in a binder.• Read the RAI User Manual and review all MDS 3.0 materials.• Write down your questions as you read the manual. Have these questions available during formal training sessions.• Please share what you have learned with others. You can email me and I will post news and information at http://www.recreativeresources.com/MDS3.0.htm as I receive it. I will also address MDS 3.0 issues on my Facebook group page at www.tiny.cc/ReCreativeResourcesonFacebook